In 2009, the Center for Healthcare Research & Transformation (CHRT) commissioned the first Cover Michigan Survey, to gain insight into the issue of health care access in Michigan. The report was released in March 2010.

One of the most important conclusions of the Cover Michigan Survey was this: having health coverage is not synonymous with having access to health care. Many respondents—even those with health coverage—reported significant barriers to obtaining affordable care.

This report presents the findings of the Cover Michigan Survey conducted in 2010, which was designed to delve deeper into key questions raised by the previous report. The specific goals of the 2010 survey were:

To describe and better understand the connection between health coverage and access to care, with an in-depth look at the current Medicaid population.

To explore issues people face when seeking and receiving medical care.

To develop an in-depth profile of health status and its connection to health coverage.

Having health coverage is significantly related to seeking and receiving needed health care and makes a tremendous difference in whether or not someone has a medical “home” for primary care. While 77 percent of respondents indicated they had a usual source for primary care, and 80 percent reported their usual place for care was in a doctor’s office, important differences emerged once the data were sorted by coverage status.

Respondents who lacked health coverage were far less likely to identify a primary care provider and to report seeking care at a doctor’s office. They were also more likely to seek care in alternative primary care settings, such as public or community health clinics. Emergency departments and urgent care facilities were also more likely to be the “usual location of care” for the uninsured.

The uninsured were half as likely as the insured to have seen a health care provider in the past 12 months, but twice as likely to report having seen a provider 10 or more times. This may be an indication of the acuity or severity of health care needs for some segments of the uninsured population.

The uninsured were also more likely to report that they had delayed receiving medical care. Specifically, 52 percent of the uninsured delayed needed medical care, compared to 20 percent of the insured. The uninsured were three times as likely to cite cost concerns as the barrier to their seeking care—64 percent compared to 21 percent, respectively.

Having health coverage is clearly important to access, but not always sufficient. In particular, access to specialty care was notably more difficult for those with Medicaid coverage.

Twenty-two percent of those with Medicaid reported having been told that the specialist they were trying to see did not accept their insurance, compared to just 11 percent of those with employer-based insurance, 6 percent of those with individually-purchased coverage, and 5 percent of those with Medicare.

Half of those respondents with Medicaid found getting an appointment with a specialist either “very difficult” or “somewhat difficult,” compared to 17 percent of respondents with Medicare, 23 percent of those with employer-based insurance, and 25 percent of those with individually-purchased coverage.

Accessing primary care was much easier for Medicaid recipients than for the uninsured, but still considerably more difficult than for those with private coverage or Medicare. Specifically:

Forty-seven percent of those with Medicaid indicated getting appointments for routine primary care was “very easy,” compared to 73 percent of those with employer-based insurance or Medicare, and 69 percent of those with individually-purchased coverage.

In addition, 42 percent of those respondents with Medicaid reported having been told that their preferred primary care provider did not accept their insurance, compared to 15 percent of those with Medicare, 12 percent of those with employer-based coverage, and 10 percent of those with individually-purchased coverage.

Access issues were not confined to adults. The parents of children with public coverage through either MIChild or Medicaid Healthy Kids also reported difficulties with access to preferred providers of care for their children.

Those with Medicaid Healthy Kids were much more likely than those with MIChild to report having been told their primary care provider would not accept their child’s coverage.

For specialty care, the differences were even more significant. Forty-six percent of those with Medicaid Healthy Kids reported having been told their specialist would not accept their child’s coverage, compared to 14 percent each of those with MIChild and private coverage (individually-purchased or employer-based coverage).

More than one in three Michigan adults reported a chronic condition, such as osteoarthritis, depression, diabetes, asthma, heart disease, or cancer.

Depression was the most commonly reported condition among survey respondents.

Reports of depression were most prevalent in the population with public coverage. Nearly one in five Medicaid beneficiaries and one in six Medicare beneficiaries reported having been diagnosed with depression. This finding underscores the importance of considering mental health, along with physical health, when looking at the health status of a population. It also emphasizes the value of access to subspecialty mental health services for individuals for whom primary care-based mental health care is not sufficient.

Health Coverage and the Uninsured

The proportion of respondents with and without health coverage remained relatively unchanged from the 2009 survey.

FIGURE 1: Self-Reported Health Coverage Status in 2010

While there were slight shifts in the sources of insurance between 2009 and 2010—a slight decrease in employer- based insurance and a slight increase in individually- purchased coverage—these differences are not statistically significant but still warrant monitoring in future surveys.

FIGURE 2: Source of Coverage

Consistent with other analyses of health coverage in Michigan, about 11 percent reported not having health coverage in 2010. According to this survey, the uninsured in Michigan are more likely to be:

Living in a rural community or small town. Fourteen percent of respondents in rural communities and 18 percent of those in small towns were uninsured, compared to just 3 percent of respondents in the suburbs, and 5 percent of those in urban communities.

Male. Fifty-five percent of the uninsured were male, compared to just 45 percent of women.

Working, but with no health coverage. Over half (54 percent) of the uninsured respondents in our sample were uninsured and working either full or part-time.

Single. Forty-three percent of the uninsured reported never having been married, compared to the 35 percent who were married but uninsured.

Low income. Over half (53 percent) of the uninsured had household incomes below $40,000 per year.

Less educated. Forty-nine percent of the uninsured had a high school diploma, a GED, or neither, compared to just 10 percent that had at least a four-year degree.

Younger. Forty-four percent of the uninsured in our sample are under age 30, while this age group comprises just 18 percent of the insured population.

Health Coverage and Access

To come to a deeper understanding of the interplay between health coverage and access to care, the 2010 survey asked a series of questions about respondents’ experiences in seeking and receiving care, and looked at their responses in light of their coverage status and source of coverage.

Source of Care

Survey respondents were asked two questions about source of care:

Do you have a personal or family doctor or other healthcare professional (such as a nurse) that you usually rely on if you need medical care?

When you are sick or need advice about your health, where do you usually go?

Both questions were designed to assess “usual sources of care”: the first to assess whether or not the respondent had an individual they identified as their usual health care provider; the second question to assess the usual location or place respondents went for medical care.

Overall, more than three-fourths of respondents (77 percent) indicated that they had someone they usually go to for medical care.

Eighty percent of respondents identified a doctor’s office as their usual location of care. Five percent went to a public or community health clinic. Four percent were seen in both urgent care facilities and hospital emergency departments, and another 2 percent were seen in hospital outpatient departments. The remaining 5 percent sought care/advice from other sources, such as the Internet, friends and family, or alternative medicine providers.

FIGURE 3: Usual Location of Care

When comparing access between the insured and uninsured, clear and statistically significant differences emerge. The uninsured were far less likely to seek medical care at a doctor’s office, and far more likely to have been seen in public or community health clinics. Emergency departments and urgent care facilities were also cited more often by the uninsured as sources of regular health care.1

FIGURE 4: Usual Location of Care, by Coverage Status

Insured

Uninsured

Doctor’s Office

86%

35%

Public or Community Health Clinic

3%

20%

Hospital Outpatient

2%

4%

Hospital Emergency Department

3%

10%

Urgent Care

3%

19%

Other

4%

13%

Total

100%

100%

The uninsured were also far less likely to have someone they could identify as a primary care provider.

FIGURE 5: Identifying a Primary Care Provider, by Coverage Status

Insured

Uninsured

Has A Primary Care Provider

81%

50%

Does Not Have Primary Care Provider

19%

50%

Total

100%

100%

These findings are consistent with national surveys that show about three-fourths of the population nationally have been able to identify a usual source of care, and that the uninsured are much less likely to have been able to identify a regular source of care compared to the insured.2

Frequency of Care

The survey asked respondents how many times in the past 12 months they had seen a provider for routine care. Approximately 80 percent of respondents indicated that they had seen a provider in the past 12 months, and approximately 20 percent indicated they had not.

FIGURE 6: Seen for Routine Care in Past 12 Months

Not surprisingly, we found that people who lacked health coverage were the least likely to have seen a health care provider for routine care in the past 12 months. Forty-three percent of the uninsured reported not having seen a provider in the past 12 months, compared to approximately 17 percent of insured respondents. Just 18 percent of the uninsured had seen a provider at least once in the past 12 months, compared to 35 percent of the insured.

FIGURE 7: Number of Times Respondent Has Been Seen by Provider in Past 12 Months, by Coverage Status

Insured

Uninsured

None

17%

43%

Once

35%

18%

Twice

20%

8%

3 to 5 times

19%

21%

6 to 9 times

5%

2%

10 or more times

5%

9%

Total

100%

100%

Interestingly, the uninsured were almost twice as likely as the insured to have seen a provider 10 or more times in the 12 months previous to the survey—approximately 9 percent of the uninsured had done so, compared to just 5 percent of the insured. This may be an indication of the acuity or severity of health care needs for some segments of the uninsured population, and points to the fact that the sickest members of our society—even without health coverage—will find their way into the health care system, but it may be in more intense care settings and in later stages of an illness.

Overall Access to Primary and Specialty Care

While it is clear that having coverage makes a difference in the way a person interacts with the health care system and whether or not they are able to identify a primary care provider, having coverage alone is not sufficient to ensure access to care. The ability to access primary and specialty care varied significantly by coverage status and type of coverage.

Overall, 14 percent of all respondents reported having been told their preferred primary care provider was not accepting their type of health coverage, compared to 10 percent of respondents who reported having been told their preferred specialist was not accepting their coverage.

FIGURE 8: Told Provider Was Not Accepting Insurance, by Provider Type

Primary Care

Specialty Care

Told Provider Was Not Accepting Coverage

14%

10%

Told Provider Was Accepting Coverage

86%

90%

Total

100%

100%

Looking at these numbers alone, it would not seem that access to primary or specialty care was a particular issue. However, a different picture emerged when looking at differences among those with different types of coverage.

Specifically, respondents with Medicaid were the most likely to report being told their primary care provider was not accepting their coverage—42 percent, compared to just 15 percent of those with Medicare, 12 percent with employer-based coverage, and 10 percent of those with individually-purchased coverage.

Respondents with Medicaid were also more likely than their counterparts with Medicare or private coverage (individually-purchased or employed-based coverage) to have been told that their specialist does not accept their coverage—22 percent of those with Medicaid reported being told this, compared to 11 percent of those with employer-based coverage, 6 percent with individually- purchased coverage, and 5 percent of those with Medicare.

Looking at access to primary and specialty care, the vast majority of overall respondents (88 percent) reported that accessing primary care for routine appointments was either “somewhat easy” or “very easy,” and 77 percent said getting an appointment with a specialist was also “somewhat easy” or “very easy.”

FIGURE 11: Ease of Getting Appointments, by Provider Type

Primary Care

Specialty Care

Very/Somewhat Easy

88%

77%

Very/Somewhat Difficult

12%

23%

Total

100%

100%

Again, however, the picture varied when looking at ease of getting appointments by coverage type.

Respondents with Medicare and private coverage (individually-purchased and employer-based coverage) reported an easier time getting appointments for routine primary care than those with Medicaid. Seventy-three percent each of those with Medicare and employer-based coverage, and 69 percent with individually-purchased coverage, reported getting primary care appointments as “very easy.” But just 47 percent of those with Medicaid reported getting primary care appointments was “very easy.”

Similarly, respondents with Medicare and private coverage also reported an easier time getting appointments with specialists than those with Medicaid. Ten percent or less of respondents with Medicare or private coverage reported getting appointments with specialists to be “very difficult,” compared with 25 percent of respondents with Medicaid coverage. Indeed, half of respondents with Medicaid reported some degree of difficulty.

Location of Care

People with Medicaid coverage were the least likely to seek care in a doctor’s office, and like the uninsured, far more likely to have used alternative locations for care, such as public or community health clinics. Respondents with Medicaid were also more likely to identify hospital emergency departments or urgent care facilities as their usual location of care.

FIGURE 14: Usual Location of Care, by Coverage Type

Source of Health Coverage

Medicare

Medicaid

Employer

Individual

Doctor’s Office

88%

63%

88%

80%

Public or Community Health Clinic

3%

16%

2%

1%

Hospital Outpatient

1%

4%

2%

1%

Hospital Emergency Department

2%

12%

1%

10%

Urgent Care

1%

4%

3%

6%

Other

6%

0%

5%

1%

Total

100%

100%

100%

100%

Access Issues for Children with Public Coverage

In last year’s Cover Michigan Survey, we analyzed differences in access to care for children with different kinds of public coverage (Medicaid Healthy Kids and MIChild) and found significant differences in the parents’ ability to find providers that accepted their child’s coverage. Specifically, we found that parents reported more difficulty in finding providers that accepted Medicaid as compared to MIChild.

For the 2010 survey, questions were designed to provide greater detail on differences between primary and specialty care access. We found significant differences in access to both types of care between children with Medicaid coverage, MIChild coverage, and those with private insurance.

Fifty-two percent of those children with Medicaid Healthy Kids were told that their primary care provider was not accepting their coverage, compared to 43 percent for MIChild, and just 15 percent for those with private coverage. The differences are even bigger with regard to specialists. Forty-six percent of those with coverage for their children through Medicaid had been told that the specialist did not accept their child’s coverage, compared to 14 percent each for those with MIChild and private coverage.

In terms of ease of getting appointments, 73 percent of those with Medicaid Healthy Kids reported that it was “very easy” or “somewhat easy” to get a primary care appointment, compared to 82 percent of those with MIChild and 94 percent of those with private coverage.

For specialty care, 57 percent of those with children with Medicaid reported it was “very easy” or “somewhat easy” to get appointments, compared to 82 percent and 86 percent for MIChild and private coverage, respectively.

Delaying Care

In 2010, nearly one in four respondents (23 percent) indicated they had delayed seeking needed care in the past six months, about the same percentage as noted in the 2009 survey (20 percent).

The reasons given for not seeking care were unchanged from 2009 to 2010—cost and lack of coverage remained the top two reasons respondent cited for not seeking care in the past six months. Even though the differences between 2009 and 2010 were not statistically significant, the trend warrants watching. National studies have found growing trends of adults delaying medical care, as well as other indicators of cost burdens related to health care.3

FIGURE 18: Reason for Not Seeking Care When Ill

The uninsured were more than twice as likely as the insured to report having delayed needed care.

Additionally, the uninsured were three times as likely to cite cost concerns as the barrier to their seeking needed medical care—64 percent compared to 21 percent, respectively.

Respondents with Medicaid coverage were more likely to have delayed care than respondents with coverage from other sources. More than one in four respondents with Medicaid reported delaying care in the past six months. Of those respondents with Medicare, approximately one in five (21 percent) reported delaying care.

FIGURE 20: Respondent Has Delayed Needed Care, by Coverage Type

Source of Health Coverage

Medicare

Medicaid

Employer

Individual

Delayed Care

21%

27%

17%

15%

Did Not Delay Care

79%

74%

83%

85%

Total

100%

100%

100%

100%

Health Status

Self-Rated Health Status

In 2010, 57 percent of respondents reported their health was either “excellent” or “very good” compared to 49 percent in 2009. While a greater proportion of the 2010 respondents indicated their health was ”good” compared to 2009 (33 percent compared to 26 percent), more respondents indicated their health either just ”fair” or “poor”—18 percent in 2010 compared to 16 percent in 2009.

FIGURE 21: Rate Your General Health

There were no statistically significant differences in general health as a function of race or gender but as one would expect, self-perceived health declined with advancing age and increased with higher income and education.

The insured reported better overall health compared to the uninsured. Respondents with Medicaid were also the most likely to report fair/poor overall health compared to their counterparts with Medicare, employer-based or individually-purchased coverage.

FIGURE 22: Self-Perceived Health Status, by Coverage Status

General Health

Insured

Uninsured

Excellent

18%

7%

Very Good

43%

30%

Good

26%

26%

Fair

9%

21%

Poor

5%

16%

Total

100%

100%

FIGURE 23: Self-Perceived Health Status, by Coverage Type

Source of Health Coverage

General Health

Medicare

Medicaid

Employer

Individual

Excellent

21%

4%

20%

25%

Very Good

29%

33%

45%

47%

Good

23%

19%

26%

23%

Fair

9%

31%

8%

4%

Poor

18%

13%

0%

1%

Total

100%

100%

100%

100%

Chronic Disease

To further assess health status, respondents were asked a series of questions regarding specific health conditions. The conditions were chosen because they have been previously identified as both prevalent in the population and significant drivers of health care spending.4 Depression was the most commonly diagnosed condition among the six conditions of interest, followed by osteoarthritis, asthma, diabetes, heart disease, and cancer.

FIGURE 24: Respondents with Specific Health Conditions

Condition

Percent with Condition

Depression

14%

Osteoarthritis

13%

Asthma

11%

Diabetes

10%

Coronary Heart Disease

8%

Cancer

8%

In the aggregate, approximately 39 percent of respondents reported having been diagnosed with any of the six chronic conditions. Twenty-two percent reported having one of the conditions, 11 percent had two, and 6 percent had three or more of the six chronic conditions.

FIGURE 25: Number of Respondents Reporting Chronic Conditions

Number of Chronic Conditions

Percent with Condition

None

62%

1

22%

2

11%

3 or more

6%

Total

100%

Looking at the conditions by coverage type, we see that Medicare beneficiaries were predictably sicker than those with other types of coverage, with one exception—persons on Medicaid were slightly more likely to have been diagnosed with or told they had depression. The most common conditions among persons with Medicaid were osteoarthritis, depression, diabetes, asthma, heart disease, and cancer. For those respondents with individually-purchased coverage, although generally the healthiest group, the most common diagnosis is cancer, second only to Medicare beneficiaries in prevalence.

In examining the differences between the insured and uninsured in the distribution of chronic conditions, with the exception of osteoarthritis, the uninsured are sicker than the insured.

FIGURE 27: Prevalence of Chronic Conditions, by Coverage Status

Condition

Insured

Uninsured

Depression

11%

32%

Asthma

10%

17%

Diabetes

9%

14%

Coronary Heart Disease

8%

10%

Cancer

7%

10%

Osteoarthritis

13%

3%

What is especially striking is the proportion of the uninsured reporting they had been diagnosed with depression. The uninsured were almost three times as likely as the insured to have been told they have depression. This finding underscores how important it is to focus on the physical and mental/behavioral health needs of the uninsured, the majority of whom will presumably be entering the health care system in 2014 with the expansion of health coverage under the Patient Protection and Affordable Care Act.

The results presented in this report demonstrate that while having health coverage is critical to getting adequate, affordable, and timely access to health care, simply having health coverage alone is not sufficient to ensure that access. Across all of our measures, the uninsured reported greater issues with access to care, and access varied significantly by the type of health coverage carried by respondents.

The uninsured were sicker than the insured and demonstrated potentially greater health care needs, especially in the area of mental health. They were also more likely to have delayed care, and a higher percentage had not been seen by a health care provider in the past 12 months (with the exception of one segment of this population that reported high utilization, presumably due to greater needs).

This point is very telling: the sickest members of our society—even without health coverage—are finding ways to get needed care. But without adequate coverage, the cost of providing that care gets absorbed elsewhere in the system.

Certainly, expanding health coverage through health reform will help address this. However—as our survey has also demonstrated—coverage is not a magic bullet to guarantee access to care.

This is a critical point that cannot be over-emphasized as the nation looks toward implementation of the Affordable Care Act and the expansion of the insured population, especially through the expansion of Medicaid.

Our analyses consistently demonstrate that those with Medicaid generally have greater difficultly in accessing primary and specialty care compared to their counterparts with Medicare or private insurance, and are less well connected to a primary care practice as the principal site of care.

Those with coverage through Michigan’s MIChild program reported better access to care than those with other forms of Medicaid coverage and could serve as a model as Medicaid coverage expansion occurs.

Those who seek to assure true access to health care and improve the continuity and coordination of care must look beyond health coverage. Integration of care across physical health and mental health dimensions will be essential to addressing both cost and quality issues, particularly in the low income population. The Affordable Care Act’s Medicaid expansion will be a boon to many, but without accompanying policy and care delivery changes, it won’t be enough to change the picture of care for our citizens most in need.

The results presented in this report were produced from a series of survey questions that were added to Michigan State University’s Institute for Public Policy and Social Research’s (IPPSR) quarterly State of the State Survey (SOSS). The survey was fielded in the last quarter of 2010 and includes a sample of 1,000 Michigan adults. The margin of error for the entire sample is +/-3.1 percent. The sampling design utilized a random stratified sample based on regions of the state.

For analytical purposes, the survey data were weighted to adjust for the unequal probabilities of selection for each stratum of the survey sample (e.g. region of the state, listed vs. unlisted telephones, etc.). Additionally, data were weighted to adjust for non-response based on age, gender, and race with the survey sample according to population distributions from the 2000 Census. Statistical significance was tested using a chi-square test for independence. Unless otherwise noted, all results reported here as statistically significant are significant at the p<.001 level.

37 percent of respondents lived in small towns or communities; 25 percent in rural areas; 22 percent lived in a suburban community; and, 14 percent lived in an urban area.

Average age of respondents was 46 years old; 17 percent of the sample were 65 years of age or older.

Respondents who reported having health coverage through Medicaid are assumed to be within Medicaid Managed Care health plans through which most adults on Medicaid in Michigan receive their coverage. This sample included the dual eligible population—those receiving coverage through both Medicare and Medicaid—but they were not included in the analysis due to their small number (less than 1 percent of the sample).

The survey sample was generally representative of the adult population in Michigan (ages 18 and older) with the exception of age. The sample was slightly older than the general population of Michigan—according to Census 2000, 14 percent of the Michigan population was age 65 or older, compared to 17 percent in our sample.

The staff of the Center for Healthcare Research & Transformation (CHRT) would like to thank the staff of the Institute for Public Policy and Social Research (IPPSR) at Michigan State University for their assistance with the design and analysis of the survey.

The Center for Healthcare Research & Transformation (CHRT) illuminates best practices and opportunities for improving health policy and practice. Based at the University of Michigan, CHRT is a non-profit partnership between U-M and Blue Cross Blue Shield of Michigan designed to promote evidence-based care delivery, improve population health, and expand access to care.